116 Suicide prevention in Finland

Finland, with a population of 5.5 million people, forms a culturally homogeneous, well-educated and well-functioning modern Western society. The Finnish health care system is mainly public, and financed by taxes collected both by the state and the municipalities (http://www.vn.fi/stm/english/).

Suicide has been one of the leading causes of death for decades. Suicide mortality has had a general increasing trend from the early 1920s to the peak of suicide rate, 30 per 100,000, in 1990. Since then, however, the suicide rate has been decreasing, and was 18 per 100,000 in 2005.

The first parliamentary committee on suicide was launched in Finland in the mid-1970s. The reason for this was the heavily increasing trend of suicide mortality, and the increasing awareness of suicide as an important public health issue. In the early 1980s, the minister of Social Affairs and Health decided to launch a novel national suicide-prevention project. The project was accepted and started officially on 1 May 1986, after about two years of preliminary preparation. The ultimate aim was to reverse the increasing trend of suicide mortality, and to decrease the suicide rate by 20 per cent during the next ten years (Upanne M et al. 1999). The project was a part of the Finnish national strategy of the WHO's ‘Health for All by the Year 2000’ programme (Ministry of Social Affairs and Health 1987). The author of this chapter was appointed the leader of the project. A separate research unit was established at the National Public Health Institute to support the management and research activities of the project.

The basic principle of the project was to build national prevention activities on the reliable picture of the current Finnish suicide situation.Some longitudinal and trans-sectional epidemiological studies on suicide mortality, based on the available Finnish mortality statistics, were performed. In collaboration with the mass media, and by arranging local public meetings and lectures, a public awareness and discussion was raised. All suicides (N = 1397) committed during one year, throughout the country, were scrutinized by using a psychological autopsy method, combined with a normal and legal police investigation, and a routine medico-legal examination.

We believed that the best way to change attitudes of the various professionals, and to find common concepts to describe suicidal behaviours, would be ‘learning by experience’. For this purpose, about 250 field researchers, mostly locally practising and experienced mental health workers (doctors, psychologists, social workers and nurses specializing in psychiatry), were trained for interviewing relatives, the next of kin and treating personnel, and for collecting other important data on every suicide case. Every suicide was discussed in the fifteen provincial project groups in the whole of Finland, including representatives of police, medico-legal experts, primary health care and social services, psychiatric services, and possibly other sectors of society. Every structured case report ended with concrete suggestions for suicide prevention, based on the findings from each individual case (Lönnqvist 1998). Altogether, about 1000 thousand people participated in the project, and more than 2000 relatives of the suicide victims, and approximately the same amount of the treating personnel interviewed in the connection of the project suicides were influenced by the project. All of them were also key suicide prevention agents in their own professional surroundings. The project had a direct impact on about 100,000 professionals and citizens, with an indirect impact through the 100,000 professionals and mass media on the whole society of Finland.

This ambitious programme extended suicide research and prevention efforts throughout the entire country. It was the first comprehensive effort of its kind anywhere (Wilson 2004).

More than one hundred scientific publications were published from the psychological autopsy sample. The major risk factors for suicide were depression, personality disorders, alcoholism, schizophrenia, and organic or other mental disorders (Henriksson et al. 1993; Lönnqvist et al. 1995). Two-thirds of suicide deaths occurred in people who were depressed, yet only 15 per cent had received appropriate treatment. Alcohol was found in the blood of half of the people who committed suicide, and one-third of all suicides were made by alcohol-dependent individuals. People who survived a previous suicide attempt were at very high risk for repeated attempts, and yet, they typically received little or no treatment or consistent follow-up.

After all suicide cases were collected and analysed, in 1987–88, the fifteen provincial project groups published their final reports in 1989–1990, with proposals for suicide prevention in their own region and province. The national strategy and action plan was worked through in 1991, by the national project group representing all main sectors of the Finnish society, and led by the director general of the National Board of Health. The national project group was supported by the project leader, secretariat and core planning team of the project group.

The national suicide prevention programme, ‘Suicide Can Be Prevented’ (National Research and Development Centre for Welfare and Health 1993) was based on the findings of a national psychological autopsy study of suicide deaths. The key targets were people with depression, substance use problems, in crisis situations, those in need of psychosocial support due to physical illnesses, and people who attempted suicide. The project focused mainly on actions that directly influenced the risk factors for suicidal behaviour. Younger generations were the main targets of the programme. Enhancing awareness and changing negative attitudes towards suicide were also in focus.

A booklet—‘Suicide can be Prevented’ (National Research and Development Centre for Welfare and Health 1993)—was distributed throughout the country to raise awareness among physicians, those working in health and social care, teachers, police officers, church leaders and other people, who all come in regular contact with potential individuals at risk for suicide. The most important advice was to take early signs of self-destructive behaviour seriously, and to always consider the possibility of suicide among people with mental disorders. Health and welfare workers were also advised to pay close attention to the well-being of patients with chronic illness or disability, who may be depressed, but do not acknowledge it.

Asking about depression and suicide should be as routine as checking for hypertension, and physicians should consider addressing these issues directly with patients. We found that patients who are feeling suicidal are likely to admit their feelings when asked by their physician, but they seldom spontaneously convey this information.

Alcohol was identified as a particularly relevant risk factor for suicide in Finland, and given priority in our suicide-prevention strategy.

Because the high rates of suicide were observed among young men in the 15–24 age group, the programme focused on this group. We launched mental health, depression and suicide awareness programmes in the school system. The military, which evaluates all 18-year-old men as part of the national Finnish draft, received special instructions on the identification and referral of at-risk youths.

The suicide preventive programme leaders also tried to train the media on appropriate suicide reporting, so that suicides did not receive sensational coverage that might encourage copycat suicides.

The Finnish government commissioned both an internal and external evaluation to assess the outcome of the strategy (Ministry of Social Affairs and Health 1999).

The principal aim of the Finnish National Suicide Prevention Project, launched in 1986, was to reduce suicide mortality by 20 per cent within ten years (Hakanen and Upanne 1966). Suicide rates were 26.6 in 1986, and actually increased during the years 1986–1990 to 30.0, which were higher than ever. The programme was not yet successful, with only a 9 per cent reduction in the incidence of suicide achieved over the entire official duration of the project (23.6 in 1996). From the beginning of the implementation phase (1991–92), the suicide rate has continuously decreased from the peak in 1990 (30.0 per 100,000) to a 1ow point of 17.9 per 100,000, in 2005. The suicide rate, in 2005, was 40 per cent lower than in 1990.

The external evaluation of the Finnish national suicide prevention project in 1999 concluded that:

Implementation was successful in putting suicide prevention on the social agenda and at large in promoting development in the chosen areas. It may already have contributed to the reversal of the increasing trend in suicide rates. It gave experiences of an interactive, participating working model and produced practical models and guidebooks for suicide preventive work. In these respects, the project has been both purposeful and appropriate and has produced good results.

Kerkhof (1999, p. 63)

In 2001, the Government of Finland developed a new public health policy called the ‘Governmental Resolution on the Health 2015 Public Program’ (Ministry of Social Affairs and Health 2001). This programme, targeted at younger generations, has been developed to reduce accidental and violent death among young adult men by one-third of the level during the late 1990s. Finland has also been active in the development of a mental health strategy, of which suicide prevention is an elementary part, both in the WHO and the European Union.